Reminder: Commercial Plan Appeals Process for 2020 eviCore® Adverse Determinations
As a reminder, for dates of service on or after Jan. 1, 2021, AIM Specialty Health® is the utilization management vendor for Blue Cross and Blue Shield of Texas (BCBSTX) commercial Prior Authorization (PA) requests that were formerly handled by eviCore Healthcare®. To assist providers with this transition, in December 2020, a notice appeared on the eviCore website to alert providers of the appeals run-out process, which will continue through April 2021.
If you submitted a PA (pre-service) request through eviCore and that request was denied or if eviCore conducted a post-service (post-claim) medical necessity review resulting in an adverse determination, your letter will instruct that peer-to-peer discussions and appeals must be requested through eviCore. Please note that, for these pre- and post-service adverse determinations, eviCore will continue to process peer-to-peer and appeal requests through April 30, 2021, only. After April 30, 2021, eviCore will redirect any peer-to-peer and appeal requests to BCBSTX.
The vendor that issued the pre- or post-service adverse determination will process any related peer-to-peer or appeals requests through April 30, 2021. For any adverse determination after Jan. 1, 2021, follow the instructions in the letter you receive from BCBSTX.
eviCore healthcare (eviCore) is an independent specialty medical benefits management company that provides utilization management services for BCBSTX.
AIM Specialty Health (AIM) is an independent company that has contracted with BCBSIL to provide utilization management services for members with coverage through BCBSTX.
Availity is a trademark of Availity, L.L.C., a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX.